31 Mar 2011


One morning last month, Szeto was rather busy and conducted a quick ward round. In the middle of the session, he overheard a medical student whisper to his classmate, “I thought renal physicians teach!”

When Szeto told us this story, we all found it hilarious. It was like complaining Feng Qingyang for not teaching Huashan Swordplay when he could actually demonstrate the Nine Swords of Dugu.

A few days later, a student representative reported his classmates’ view on clinical teaching at our department meeting. This led to heated discussion on how clinical medicine should be taught. Most professors stressed that we should not spoon feed students by providing a lot of factual knowledge at ward rounds and tutorials. Rather, if the students knew the patients and their clinical progress, they should have already learned much by observing how clinicians made decisions on treatment.

Last year, after our Boss took up the post as the VC, JW arranged some media interviews to celebrate the event. Somehow, I was labeled as the last trainee of Boss. What an honor!

During the interview, I had to recall how Boss taught me. The reflection surprised me. During my entire training from medical student to specialist, I had one tutorial by him on inflammatory bowel disease. He also observed me do one gastroscopy and one ERCP. Both procedures failed. That’s all. According to today’s standard, I should file a complaint at the College for not receiving proper teaching.

But I learned much more than that. At ward rounds, he showed us how to care for patients and gain their trust. He showed us how to ask important questions. At casual talks, he shared his experience with a bad boss and a good boss, and how the past modeled his choices.

And for the rest, I cannot see why I cannot get the information from books and journals. I think this is more than enough. But how can I make our students believe this is really good enough?

24 Mar 2011

Music Lessons

It is often said that medicine is half science and half art. In Annals of Internal Medicine last week, Dr Frank Davidoff, Editor Emeritus of the journal, went as far as discussing what doctors might learn from musicians.

Reflecting on my own musical training in the past, I would say practice is one of the most important things that I have learned.

Practice is not mechanical repetition of the same movements. It is both a motional and mental process that involves the following steps in cycles: Trial, reflection and experimentation. Without the ability to reflect and the interest to experiment, one may do the same job for the whole life without any improvement. Before a student can do this on her own, it is the responsibility of the teacher to complete the cycle.

Practice takes time. Arthur Rubinstein was born to play Chopin – after years of practice. Similarly, good doctor-patient relationship and clinical sense cannot be developed in the library. You have to interact with patients. It hurts to see some doctors quarreling with patients all the time and never think how they may do it better.

“If I don’t practice for a day, I know it; if I don’t practice for two days, the critics know it; if I don’t practice for a week, everyone knows it.” Having said that, the time required to maintain a skill depends on the level of skill you want to have. Practicing 30 minutes per day (when Angelina is doing something else), I am quite comfortable with Mozart’s Sonatas. If I am to play Beethoven’s Appassionata for others, I would have to practice eight hours per day. By the same token, Szeto reads medical textbooks for 30 minutes everyday to maintain his medical knowledge. I am embarrassed to report when I last opened the Harrison Textbook of Medicine.

17 Mar 2011

Joint Decision

After so many brainwashing meetings – I mean brainstorming – I start to wonder how best decisions should be made. Is more people better? With more people, information may be shared and loopholes may be filled. But will this affect efficiency?

In the February issue of the Proceedings of the National Academy of Sciences, an interesting experiment by Ashley Ward and colleagues tested the effect of the number of members on decision making using mosquitofish, Gambusia holbrooki, from Australia. In the study, the fish was put to swim in a Y-shaped maze. In one of the arms hid a 12 cm replica predator. The mosquitofish were considered to have made the correct decision if they avoided the predator and swam to the other arm.

As predicted, the bigger the number of fish in the shoal, the more likely the fish would make correct decisions. Was that due to higher chance of including a clever fish in a bigger shoal? When each fish was tested in isolation, none of them performed significantly better than the others.

Now come the more interesting part. Contrary to our anticipation, bigger shoals always made quicker decisions than smaller ones. It turned out that the decision speed was determined by the first fish that made the decision, probably after it had caught sight of the predator. When there were more fish, the time for any one fish to spot the predator and start moving was shorter.

Can we learn a thing or two from mosquitofish?

I can see you shaking your head. Above all, Homo sapiens are not called the crown of creation for nothing. As advanced species, we always have experts who can see the whole picture when frontline workers can’t. Besides, we will never bump into a predator in ten seconds. With the new time-out exercise, it will take at least five minutes before we start swimming. Even if we bump into the predator despite all precautions, we still have the Advanced Incidents Reporting System (AIRS). In short, our system is fool-proof.

To me, the major drawback of following the mosquitofish model is that my voice will never be heard. The fastest fish, GW, will make all decisions at grand rounds before the rest of us can understand what is happening to the patients. Having said that, is it all that bad? Should I not benefit more by using the time to ask what stocks JW have bought recently?

The above discussion, as usual, is off the point. Brainstorming meetings are never meant for decision making, I know.

10 Mar 2011


It all began in Tunisia. Soon the Year of Revolution swept through Middle East. At a smaller scale, our local young doctors also voiced out their need and aspirations. I am no fan of the butterfly effect, but the mood is indeed infectious.

Last week, our department administrators held a brainstorm meeting with the medical officers. I was secretly sorry for them as they had little to offer unless radical changes occurred at the head office level. Nevertheless, it is good to listen. At least it is better than saying “When I was a medical officer, I worked 90 hours a week and had ward rounds every weekend”.

There are a few problems that cannot be solved overnight. The lack of promotional prospect is not a unique phenomenon in hospitals but also occur in other areas as middle-grade posts are occupied by people of the generation X. The monopolization of professional training by the public institution also encourages it to disregard the benefits and morale of its staff until recently. That said, these problems are still easy to solve when the institution realizes the need to improve the pay and recognition to frontline doctors. The real difficulty stems from the insufficient supply of new doctors and the huge salary gap between the public and private sectors.

In the past, most politicians representing the medical field were from the private sector. Understandably, they did their best to stop the number of medical graduates from growing. With changing political paradigm, we are finally expecting 320 new graduates per year in Hong Kong several years later. Time will tell if the pendulum will over swing again this time.

Having visited many cities in mainland China, I could not help noticing that many medical schools produced huge numbers of doctors. A medical school serving a population similar to that of Hong Kong may have 5000 graduates per year. This makes our own number look ridiculous. True, the doctor-to-patient ratio in China remains low. However, at the present level of development, urban hospitals cannot absorb these graduates. As a result, most graduates have to find other kinds of jobs (e.g. sales representatives of pharmaceutical companies) or work in rural clinics with little prospect.

Of course, the increase in medical student quota in Hong Kong is trivial compared to what happens in China. Nonetheless, with increasing supply the salary will likely drop gradually. This is certainly good news to patients and the community. It is however intriguing to speculate what will happen when the medical profession becomes less profitable. Will we still be able to recruit the best students? When the dollar sign shrinks, will we actually get more passionate candidates?

3 Mar 2011


Szeto had some interesting discussions on eternity recently. (See http://ccszeto.blogspot.com/2011/02/eternal.html). As practising doctors, we need both learning skills and the desire to learn to keep up with the changing world. Without learning skills, the acquisition of knowledge is inefficient. Without the desire to learn, those skills are empty. Whenever young doctors or medical students say there is so much that they do not know, I reassure them medicine is after all for lifelong learning.

Some years ago, a postgraduate student asked his supervisor, “Professor, I really don’t know anything. What should I do?”

The professor answered, “When you think you know everything, they give you a bachelor degree. After you have learned that you don’t know anything, they give you a master degree. If you realize that not only do you not know anything but others are not better off, it is time you get your PhD.”

As such, we should not worry when so many final year students say they are not ready to be doctors. They have progressed to the stage of that postgraduate student and should join our master program. (http://www.idd.med.cuhk.edu.hk/msc-in-gastroenterology.html)

Conflict of interest statement: None declared.